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2.02.2016

Up Close with Dr. Jeffrey Goldberger: ‘We Need People to Rally Around Heart Research’

Chief of Cardiovascular Medicine Jeffrey Goldberger, M.D., M.B.A., joined UHealth – the University of Miami Health System in November. He hails from Northwestern University, where he pioneered groundbreaking heart mapping and stroke prevention tools that he’s brought to UHealth to improve the health outcomes of patients with atrial fibrillation (A-fib).

A cardiac electrophysiologist for more than 25 years, Goldberger, professor of medicine, is recognized as a leader and innovator. In treating heart disorders, he has always seen patients as individuals, which prompted him to devise precision medicine solutions to better detect and treat patients.

A-Fib is one of the most common heart rhythm disorders. It causes the heart to beat extremely fast and can eventually lead to heart failure or stroke. Goldberger’s Morphology Recurrence Plot (MRP) heart mapping technology is the first and only tool of its kind in the U.S. that identifies the exact source of A-fib based on the morphology of the electrical signals. This tool may allow ablation using radiofrequency energy to be targeted to the cells contributing to A-fib. His team also developed another revolutionary technique that measures cardiac blood flow with an MRI to better identify which A-fib patients are at risk for stroke.

“These are potentially groundbreaking technologies. If we show that they are effective, it will change the way we practice,” said Goldberger, whose first order of business at UHealth was starting the new Center for Atrial Fibrillation, which will be evaluating and developing these tools.

The top-rated cardiologist chats with Medical Communications about his long-time admiration for the University of Miami, his inspirations, and his vision for the new Center for Atrial Fibrillation at UHealth.

What attracted you to UM?
The University of Miami has a long, rich history in cardiac electrophysiology and arrhythmia research. It’s really the only institution in Miami with this level of expertise, which gives it a huge advantage in providing options for patients. Also, cardiology is currently in a noted time of transition, and I thought that in joining the team, we’d have a lot of opportunity to further pioneer cardiology research and establish the most comprehensive patient-centered care in the region.

Tell us about your upbringing and why you pursued medicine.
I grew up in Los Angeles and was there through high school, which is when I started taking a liking to medicine. I’ve always had a strong interest in math and science. Of course, lots of people have those aspirations but it often dissipates. But the interest stayed with me through my college years at MIT in Boston. The humanitarian side of helping people also sustained my interest. I went to medical school and completed my residency at the Albert Einstein College of Medicine in New York.

What led you to choose cardiology and electrophysiology?
A lot of my mentors were cardiologists, so it was a natural transition during my residency. From there, I moved to cardiology training at the University of California San Francisco, which had a strong pioneering program in cardiac electrophysiology, and that was an exciting time in the field with rapid changes and novel developments, which really drew me into the subspecialty. I also had an interest in research. With my strong math and science background, I figured that research with technology and bioengineering would be a good career choice. At the University of California at Berkeley I audited courses in engineering and signal processing. That’s really been a huge bonus and a large part of what I’ve been involved in for the past 25 years.

What are some of your greatest accomplishments?
Over the past 25 years I’ve built a pretty fair cadre of patients and expertise. Being recognized by my colleagues as an expert has been gratifying. On the research front I’ve been involved in several major initiatives. My group has done a lot in understanding the effects of the nervous system on the heart and ways to assess that.

Explain your newest heart mapping technology.
The Morphology Recurrence Plot mapping is a minimally invasive procedure. A catheter is inserted and by recording electric impulses in the heart, a plot is created showing in red where the abnormal areas are located. With this tool, we believe we will be able to precisely identify the location of the A-fib source. Initially this procedure will be used on patients who have already had an ablation procedure, but still suffer from A-fib. With this new diagnostic tool, we hope to more confidently eliminate those heart muscle cells contributing to A-fib. This will be so beneficial to patients who have suffered for years with A-fib.

Explain your new stroke prevention diagnostic tool.
The way we asses patients with A-fib to see if they are at risk for stroke is called the CHA2DS2-VASc score, which is based on a number of factors like age and blood pressure. It’s essentially a point system that’s broadly applied to each A-fib patient. The problem with those kinds of population-based risk scores is that they don’t afford enough information to make decisions for an individual patient. It’s true that, on average, risk for stroke increases with age, but there is nothing magical about having your 65th birthday that increases an individual’s risk even though their risk score increases. It turns out that the risk score-based test is only slightly better than the flip of a coin.

We determined that we need to develop a test for individuals, and one of the major determinants for an individual’s risk for stroke is how well the blood flows in the atrium, because when blood stagnates it clots. And blood stagnation is very common in A-fib. Blood clots may form in the upper chamber of the heart. If the clots travel to the head or other places, it can cause a stroke or other problems. I and my radiology colleagues at Northwestern applied a technique called 4D Flow MRI to measure blood flow in the atrium. It measures the 3D velocity over time, with time being the fourth dimension. This technology is done on a standard MRI machine with special software and analysis that delineates the blood flow.

Tell us about the other new centers for heart care that you will be starting at UHealth.
After we start the Center for A-Fib, we will focus on the Center for Valvular Disease and the Center for Cardiovascular Innovation. The centers will reflect our multidisciplinary expertise, and will have advanced clinical care, research and educational missions. The idea is that too often we become siloed in our thinking and practice. Aligning physicians with different perspectives and skill sets can really enhance the care patients receive. The educational component of the centers is important, as it will allow our cardiologists to share information, resources and research with their peers at other academic medical institutions and in turn provide awareness and enhanced care to the South Florida community.

How would you describe your relationship with your patients?
I’ve been taking care of some patients for over 20 years. I think they appreciate the time I spend with them, and, more importantly, that I listen to them and their concerns. Too often, physicians don’t listen to what the patient wants. For instance, two patients with the same critical problem may desire different modes of treatment, with one patient choosing a more conservative approach than the other. So I try to focus on what the patient wants and use this information to modulate how we approach things.

In what ways would you like to educate the South Florida community?
Heart disease is still the Number One killer of people in the U.S., and for some reason it has less glitz than other diseases. In the past decade, there’s been a revolution in cardiac technology. But there are also huge knowledge gaps. Just like communities rally around certain causes to get support for research, we need people to rally around heart research, which gets disproportionately lower research funding.

What does precision medicine mean for cardiology?
Years ago, doctors practiced individualized care because that’s what they had to do since there was no systematic way of doing things. However, data gained from clinical trials led to more recipe-type approaches based on guidelines. While these guidelines based on the results of clinical trials have been extremely helpful, we have also appreciated that not everyone who participates in a clinical trial necessarily responds well or benefits the same from the treatments that are tested in that clinical trial. We need to figure out how to get the treatment to those who benefit and avoid using it in the subgroups that do not benefit or may even be harmed by the treatment. Precision medicine allows us to be more sophisticated in pinpointing the underlying causes of heart conditions in individuals and using a precise approach for diagnostics and targeted treatment.

Precision medicine also has a role in A-fib ablation. Currently, ablations for A-fib are done based on assumptions of where the source of the atrial fibrillation is. This practice started when electrophysiologists first set out to identify the right spot to perform the ablation. The first approaches were focused on finding the triggers, and it turned out that a lot of the triggers came from an area in the atrium near or in the pulmonary veins, which are the veins that drain blood from the lungs into the left atrium. But the actual number of people in whom we could identify an arrhythmia stemming from the pulmonary veins was exceedingly small. However, to try and help more patients with A-fib, cardiologists started doing ablations based on the assumption that the arrhythmia was coming from the pulmonary vein. That did provide some benefit, but not enough. Other empirical approaches were developed to further try and improve the success rate, but also unsuccessfully. To date, we have been unable to get back to the basics: mapping the arrhythmia to identify the sources of A-fib. This is a huge knowledge gap.

Was your frustration with this practice the impetus for developing the new MRP heart mapping system?
Yes, it was very frustrating because I know that if I have a patient with ventricular tachycardia, which is a potentially life-threatening heart rhythm problem, I can take them into the electrophysiology laboratory, induce the arrhythmia, map the precise location, and use this information to guide the ablation. But we cannot do that for A-fib ablation. We could really only take a statistical approach and target the likely triggers. Our group decided that we have to find a way to identify those sources.

What are some of your hobbies?
I enjoy exercise and racquetball. I also spend a lot of time with my family and volunteering in the community. I have served in a number of leadership positions in various community organizations.

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